Wednesday, June 14, 2017

No Chicken Little, It's Just a Budget Cut -- And Mental Health Care Doesn't Have to Suffer

The recently released Trump Administration’s 2018 proposed budget includes a roughly 18% cut in funding to the National Institutes of Health (NIH), with a proportional decrease in the funds allocated to mental health. Cuts were also proposed to the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as to Medicaid and the Centers for Disease Control and Prevention (CDC), all of which provide some level of services for Americans with mental and behavioral health issues. Not unsurprisingly, this has resulted in panicked outrage from those with a vested interest in maintaining ‒ or growing ‒ funding for mental health research and services.

Within the NIH’s proposed budget of $26.92 billion, it is difficult to tabulate the actual total funds appropriated for mental health due to the convoluted structure of the organization. But to be clear, the “draconian cuts” in funding that the American Psychiatric Association (APA) referenced in its May 2017 press release criticizing the budget are a decrease in the National Institute of Mental Health (NIMH) budget from $1.545 billion in 2017, to a proposed $1.245 billion in 2018 – a decrease of $300 million, or roughly 5.9 hours of accrued interest on our national debt clock.

While admittedly the United States has a significant population with mental illness (estimates are 1 in 8 Americans), and a worrisome problem with drug and alcohol addiction, there is limited credible evidence that years of generous funding of the NIH, or of mental health programs, has had any significant positive impact on the problem. Despite the APA’s assertion that “proposed budget cuts will roll back much of the recent advances the nation has made in terms of healthcare,” exorbitant sums of taxpayer dollars spent on mental health research over the past several decades have done little to stem the rise of mental illness. In fact, essentially all of NIH’s funding, and most of the CDC’s, is spent on research. It is entirely unclear what portion, if any, of these cuts would actually impact patient care. The APA’s argument proposes a direct correlation between research and treatment that simply has not been proven to exist.

Furthermore, unlike other areas of medicine and healthcare, the field of mental health is unfortunately lacking in well-established, universal standards and guidelines when it comes to treatment, a particular challenge to the mental health care field. In fact, the NIMH’s own website cites lack of valid metrics for measuring the quality and efficacy of mental health care. In what other industry can you command the dollars that mental health does without producing results and evidence of treatment efficacy? Perhaps a better strategy is to reallocate dollars to improve training and reimbursement for primary care physicians to address mental health issues and increase access to mental health services for patients within their practices, rather than to continue funding research and programs that have not proven useful.

A significant problem here – and one that is not specific to mental health – is how taxpayer dollars are allocated during the budget process in the first place. The NIH’s Justification of Estimates for Appropriations Committees” requesting $26.92 billion references the NIH-Wide Strategic Plan for fiscal years 2016-2020 and its “commitment to responsible stewardship of public funds by conducting research to help battle public health crises including efforts to fight the opioid epidemic.” Unfortunately, that seems a tad vague when it comes to commandeering tens of billions of taxpayer dollars. From a healthcare policy perspective, the practice of block-granting agencies and organizations is inherently flawed because it rests on the assumption that a particular agency is running efficiently and that monies are spent appropriately. In addition to enabling waste, fraud, and abuse, the process is rigid and slow to adapt to new public health needs or threats. The fact remains that research only battles public health crises if it meaningfully directs treatment.

Balancing a budget is always difficult, and being held accountable to the public trust is a weighty responsibility. Agencies can easily find 18% research and administrative pork to eliminate. Without separating the scientific endeavor of research from effective treatment and improved clinical outcomes, the fevered claim of a moral imperative to fund “vital programs and initiatives” is nothing more than political rhetoric aimed at vilifying the engineer while hoping to stoke the gravy train.